NICU Case Presentation

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NICU Case Presentation
Jon Palma, MD
Neonatology Fellow
March 2010
Clinical scenario
 You are called to attend a delivery in L&D for a diagnosis of
maternal chorioamnionitis.
 Upon entering the delivery room, what minimal information must
you obtain (according to NRP guidelines)?
Question 1
Upon entering the delivery room, what minimal information must
you obtain (according to NRP guidelines)?
•Singleton or multiple gestation
•Estimated gestational age
•Presence of meconium
Case (cont’d): in the delivery room
 The OB team tells you:
 Mom is a G1 P0 at 38 weeks, and meconium is not present.
 You were called because chorioamnionitis was diagnosed for a fever of
38.3 celsius
 Next questions:
 What are the diagnostic criteria for chorioamnionitis?
 In regards to sepsis risk factors, what items must you determine from
mom’s history?
 At LPCH, for what indications do we perform full sepsis evaluations on
newborn infants?
Question 2
What are the diagnostic criteria for chorioamnionitis?
 The essential clinical criteria is maternal fever > 38 degrees
C (100.4 F); other criteria are insensitive.
 For clinical research, diagnosis is typically based upon the
presence of maternal fever and at least two of the following:





Maternal leukocytosis (>15,000 cells/cubic millimeter)
Maternal tachycardia (>100 beats/minute)
Fetal tachycardia (>160 beats/minute)
Uterine tenderness
Foul smelling amniotic fluid
 Bottom line: chorioamnionitis is a clinical diagnosis made by
the obstetrician. If they say it’s chorio, then it is.
Question 3:
In regards to sepsis risk factors, what items must you
determine from mom’s history?
 Estimated gestation
 Preterm labor
 Rupture of membranes (ROM)
 Prolonged ROM (PROM): >18 hrs
 Premature preterm ROM (PPROM):
 ROM prior to the onset of labor at a gestation of <37 weeks
 GBS status
 Including history of a prior infant with GBS infection
Odds Ratios for Neonatal Sepsis Associated
with Maternal Risk Factors
Question 4:
At LPCH, for what indications do we perform full sepsis
evaluations on newborn infants?
 Certain babies are at such high risk for infection that they should
be admitted to the NICU, regardless of clinical appearance. They
should undergo a complete evaluation for possible sepsis and be
started on empiric antibiotic therapy until infection is ruled out.
These babies include those whose mothers have:
 premature pre-term ROM
 chorioamnionitis
 a history of having a prior infant with GBS infection*
*If mother received adequate IP prophylaxis, the CDC guidelines support
observation, but clinicians and parents may opt for a complete diagnostic evaluation
Source: NICU Manual
CDC Guidelines
Approach for empiric management of newborns born to women who receive intrapartum
antibiotics to prevent early-onset GBS disease or to treat suspected chorioamnionitis
Note: in the setting of adequate intrapartum antibiotic prophylaxis for GBS and no
concern for chorio, labs are not required but a 48 hour observation period is
recommended (no early discharge)
CDC Guidelines
Intrapartum Antibiotic Prophylaxis (IAP)
 Adequate IAP
 Penicillin, ampicillin, or cefazolin > 4 hrs before delivery
 Penicillin is the agent of choice (narrower spectrum)
 Clindamycin or erythromycin > 4 hrs before delivery in:
 Penicillin-allergic women at high risk for anaphylaxis
 With GBS isolates sensitive to clinda or erythro
 Vancomycin > 4 hrs before delivery in:
 Penicillin-allergic women at high risk for anaphylaxis
 When clinda or erythro are not options because of in vitro resistance
or unknown susceptibility
 Without susceptibility testing of GBS isolates clindamycin is not
considered adequate IAP
 Usually would not send screening labs, but use clinical judgment
Case (cont’d): over to the NICU
 The baby required only routine resuscitation (warmth, drying,
suctioning, and stimulation) and had APGAR scores of 8 at one
minute and 9 at five minutes of life.
 You proceed to the NICU to perform a full sepsis evaluation.
 What constitutes a full sepsis evaluation of a newborn in the
LPCH NICU, including laboratory studies and empiric antibiotics?
Question 5:
What constitutes a full sepsis evaluation of a newborn in the LPCH
NICU, including laboratory studies and empiric antibiotics?
 CBC with differential, blood culture, glucose
 2 CRPs at least 24h apart
 The first CRP should be drawn at > 8h after birth or after the blood culture is drawn,
whichever is later
 Lumbar puncture




Tube 1: CSF glucose, protein
Tube 2: CSF culture/gram stain (changed to tube 2 to decrease false +’s)
Tube 3: CSF cell count/diff
Tube 4: if needed for other studies (e.g. HSV PCR)
 Empiric antibiotics (while awaiting culture(s), CRPs)
 Ampicillin 50mg/kg IV q6h (meningitic dose100 mg/kg IV q6h for sicker babies)
 Gentamicin 4mg/kg IV loading dose, followed by 3 mg/kg IV q24h
 For infants with respiratory symptoms
 CXR
 ETT aspirate (if intubated)
“Serial CRP levels are useful in the diagnostic
evaluation of neonates with suspected infection.
Two CRP levels <1 mg/dL obtained 24 hours
apart, 8 to 48 hours after presentation, indicate
that bacterial infection is unlikely.”
from Pediatrics 1998; 102 (4): e41
CRP has excellent negative predictive value
In the study, CRP #2 was the lab sent at least 8 hours after the initial evaluation, and CRP #3
was sent 24 hours later. CRP #1 was done at the time of the initial evaluation.
What About ET Aspirates and Urine Specimens?
 For babies who have just been intubated for respiratory distress
and have an infiltrate on chest x-ray, culture of an endotracheal
aspirate will be positive in approximately 8%. Fewer than half
of these positive cultures are associated with positive
blood cultures, so don’t forget to order an endotracheal
aspirate Gram stain and culture.
 Urine cultures are rarely positive in the first 48 hours of life.
After that, they may be quite helpful. Because they are almost
always contaminated, often with a single organism, bag urine
specimens are useless. Specimens obtained by catheterization of
the bladder are better, but also have a surprisingly high
contamination rate. Learn to do suprapubic aspirates for
urine cultures in neonates.
Source: NICU Manual
Question 6:
How do the LPCH NICU practices vary from CDC guidelines?
*
*The CDC will be revising its guidelines in 2010
to clarify that for infants who are admitted
because of risk factors (chorio) but are well
appearing, the lumbar puncture may be deferred
Question 6:
How do the LPCH NICU practices vary from CDC guidelines?
 CRP not part of CDC guidelines
 Lumbar puncture is always performed when an infant demonstrates clinical
symptoms of possible sepsis
 Rationale: there is no surrogate blood test for meningitis; only CSF
analysis provide diagnostic clues, and a diagnosis of meningitis impacts
length of antibiotic therapy. Blood cultures are negative in about 1/3 of
meningitis cases and thus should not be used in lieu of
 Limited evaluation at LPCH does not include a blood culture
 Rationale: if the index of suspicion is high enough to perform a blood
culture, treatment with antibiotics is warranted
 What is the approach to sepsis screening in the LPCH Well Baby Nursery?
 LPCH Well Baby Nursey Website - Sepsis Screen
Practical Aspects of the Sepsis Evaluation
 Draw the blood culture as soon as possible - preferably before
antibiotics are given, but start treatment without delay. The
initial dose of ampicillin can be given as an IV bolus, and the first
dose of gentamicin can be given IM if the infant is not in shock.
 As many as 50% of neonates with meningitis may have
negative blood cultures, so the CSF culture may be the only
source of a bacteriologic diagnosis. Do the LP as soon as possible;
it is not appropriate to defer it for a few hours, either for the
convenience of the caretakers or until the baby is more stable.
Source: NICU Manual
Question 7:
How are CRP results generally interpreted and managed
in the LPCH NICU?
 In an asymptomatic infant with negative cultures:
CRP < 1
negative
d/c abx if CRP negative x 2 (24h apart)*
CRP 1 – 2
indeterminate
Follow up CRP in 24 hours
CRP > 2
positive
Discuss with your attending regarding duration of abx
*Note:
the NPV of serial CRPs means that antibiotics may be discontinued prior to the blood culture
reaching 48 hours
 In a symptomatic infant with negative cultures:
 Discuss with your attending
Question 8:
What is the duration of treatment for neonates with
confirmed serious bacterial infections?
 Positive blood culture*, UTI, or pneumonia




Coag-negative Staph: 7d
Other gram-positives: 10d
Gram-negatives: 14d
Candida: 21d
 Meningitis#
 Gram-positive: 14d
 Gram-negative: 21d
Count should begin from first negative culture
# Repeat lumbar puncture recommended to document negative culture
prior to discontinuing antibiotics
*
Additional references




Uptodate.com (Intraamniotic infections)
Benitz. Suspected sepsis in newborn infants. NICU Manual.
http://www.cdc.gov/groupbstrep/guidelines/summary.htm
http://newborns.stanford.edu/ClinicalGuidelines.html
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